Stesura Seveso 441Archivio Italiano di Urologia e Andrologia 2021; 93, 4 ORIGINAL PAPER No conflict of interest declared. ation of these patients. Hence the information gained from urodynamics may help us. Performing urodynamics is controversial before surgical treatment of stress urinary incontinence (SUI) (3). According to the Cochrane library, urodynamics can change the clinical decision (4). The NICE (National Institute for health and care excellence) guideline recommends urodynamic examination before stress urinary incontinence surgery (5). EAU guidelines do not recommend routinely carrying out urodynamics when offering treatment for uncomplicated urinary incontinence (6). Incontinence mostly develops as a result of urine storage dysfunction and the incidence of bladder outlet obstruction (BOO) is low. For this reason, in daily practice, the only cystometry is usually performed in addition to history and physical examination. Since pressure-flow studies (PFS) are generally not implemented, the diagnosis of uri- nary voiding dysfunctions can be overlooked. Thus redundant surgical procedures and improper treatments can be applied to these patients. To clarify whether SUI patients are always pure SUI and if these patients should be submitted to urodynamic before surgery to prevent incorrect surgical approach, we aimed to retrospectively investigate the abnormalities in the voiding phase of female patients who have undergone PFS for incontinence. MATERIALS AND METHODS Between January 2010 and June 2015, 1329 female patients aged 18-60 who had incontinence for at least six months and underwent urodynamics were evaluated ret- rospectively. Neurogenic lower urinary system dysfunc- tion, active urinary infection, bladder stone, urethral stricture, pelvic radiation, pelvic surgery history, and patients who could not perform micturition in PFS were excluded from the study (311 patients). Patients' demographic properties, urination diary, pad test, urine analysis and culture, urethral mobility (Q tip), urinary ultrasonography, post-voided residue, and urody- namic examination findings were retrieved. At filling cys- tometry, urinary incontinence triggered with Valsalva or coughing was accepted as stress type urinary inconti- Objective: To investigate the differences between urodynamic findings and history in women with urinary incontinence before surgery and clarify the need for preoperative pressure-flow studies. Materials and methods: The medical records of 1018 women who underwent urodynamic examination for urinary inconti- nence between 2010 and 2015 were evaluated retrospectively. Stress (n = 442), urge (n = 334) and mixed (n = 242) were clas- sified as type urinary incontinence according to urodynamics. The voiding phase findings of the patients were examined. Results: The mean age of the patients was 47.85 ± 0.27 years. 18.4% of patients (n = 187) had voiding phase problems. Furthermore, this condition was seen in the most urge inconti- nence type urinary incontinence (35%). There was a statistically significant difference between the groups' voiding phase findings (p < 0.0001). The relationship between the patient's history and international consultation on incontinence questionnaire form scoring (ICIQ) and the urodynamics results showed no excellent correlation. Conclusions: Voiding phase abnormalities are not uncommon in patients with urinary incontinence. They should be considered in the evaluation of patients. Voiding phase findings may show sig- nificant differences between urodynamic data and history. Besides, the data obtained with the questionnaire forms were significantly different from the findings obtained by urodynam- ics. Consequently, urodynamics may change pre-operative clini- cal decision. KEY WORDS: Urinary incontinence; Urodynamics; Voiding. Submitted 28 February 2021; Accepted 14 June 2021 INTRODUCTION Urinary incontinence is a common health condition that can affect about 50% of adult women and decrease life quality (1). This condition increases with age. Ten to twenty percent of women and up to 77% of women resid- ing in nursing homes have urinary incontinence, yet only 25% attempt or receive treatment (2). In the evaluation of incontinence patients, the history alone may be insufficient to diagnose and classification. Understanding lower urinary tract function and revealing the underlying pathophysiology is essential for the evalu- In women with incontinence, the need for pressure-flow study before surgery and abnormalities in the voiding phase. An up-to-date comment on the available problem accompanied by literature Kutluhan Erdem, Alper Coşkun, Fatih Üstün, Fatih Tarhan Department of Urology, University of Health Sciences, Kartal Dr. Lutfi Kırdar City Hospital, Istanbul, Turkey. DOI: 10.4081/aiua.2021.4.441 Summary Archivio Italiano di Urologia e Andrologia 2021; 93, 4 K. Erdem, A.Coşkun, F. Üstün, F. Tarhan 442 nence, involuntary and inhibited detrusor contractions as urge urinary incontinence and the presence of both find- ings as mixed urinary incontinence. At PFS, the inability of contraction at sufficient force or continuity resulting in prolonged or insufficient bladder discharge was considered underactive detrusor, Qmax > 12 ml/sec and Pdet Qmax > 20 cm H2O was considered as BOO. Voiding characterized by an intermittent or stacca- to flow pattern due to involuntary and irregular pelvic floor contractions in neurologically healthful patients was evaluated as dysfunctional voiding (7, 8). The patients were grouped as stress, urge, and mixed type urinary incontinence. Whether the voiding phase find- ings of the patients were normal or abnormal was checked. Urodynamics was applied according to the International Continence Association (ICS) (4). Chi-square test was utilized to evaluate the results with Prism 5.0 (GraphPad, USA) program. P value < 0.05 was accepted as statistically significant. RESULTS The average age of the patients was 47.85 ± 0.27 years. Of the patients, 442 (43%) were evaluated as stress-type, 334 (32%) as urge-type, and 242 (25%) as mixed-type incontinence (Figure 1). Urethral stricture was diagnosed in 6% (n = 11) of those with excretory phase problems, dysfunctional voiding in 51% (n = 96) and underactive detrusor in 43% (n = 80). Urethral stricture and dysfunc- tional voiding and the rate of underactive detrusor were higher in patients with urge-type urinary incontinence. (47%) (Table 1). Another finding was lack of good correlation between his- tory and urodynamic filling phase results (Table 2). Similarly, data from International Consultation on Incontinence Questionnaire form (ICIQ) and findings from urodynamics are not fully concordant. There are consid- erable differences, especially in mixed urinary inconti- nence (Table 3). DISCUSSION The bladder should be able to store urine at low pressure and at an appropriate volume, discharge the stored urine at once, and coordinate detrusor contraction and sphinc- ter relaxation during voiding. The knowledge regarding the togetherness of urinary voiding dysfunctions in female patients with incontinence in the literature is unclear. In 18.4% (n = 187), we found that patients with incontinence also have voiding phase problems simultaneously. Additionally urethral stricture was found in 6% (n = 11), dysfunctional voiding in 51% (n = 96), and underactive detrusor in 43% (n = 80) of these patients. We established that our outcomes were consistent with the literature (7). Table 1. The voiding phase findings detected in the PFS. Groups Voiding phase findings (n) (%) Stress urinary incontinence (n = 442) Normal 403 91 Urethral stricture 0 0 Dysfunctional voiding 15 3 Underactive detrusor 24 6 Urge type urinary incontinence (n = 334) Normal 216 65 Uretral stricture 9 3 Dysfunctional voiding 71 21 Underactive detrusor 38 11 Mixed type urinary incontinence (n = 242) Normal 212 88 Uretral stricture 2 1 Dysfunctional voiding 10 4 Underactive detrusor 18 7 PFS: Pressure-flow study. Table 2. Comparison of anamnesis and filling phase findings. Anamnesis Filling phase (n) (%) SUI (n = 148) SUI (69) 47 UUI (37) 25 MUI (42) 28 UUI (n = 120) SUI (46) 38 UUI (44) 37 MUI (30) 25 MUI (n = 750) SUI (326) 43 UUI (266) 35 MUI (172) 22 SUI: Stress urinary incontinence; UUI: Urge urinary incontinence; MUI: Mixed urinary incontinence. Table 3. Comparison of ICIQ and filling phase findings. Figure 1. Incontinence types and percentages. Anamnesis Filling phase (n) (%) SUI (n = 123 ) SUI (60) 49 UUI (31) 25 MUI (32) 26 UUI (n = 116) SUI (50) 43 UUI (40) 35 MUI (26) 22 MUI (n = 779) SUI (325) 42 UUI (271) 35 MUI (183) 23 SUI: Stress urinary incontinence; UUI: Urge urinary incontinence; MUI: Mixed urinary incontinence; ICIQ: International consultation on incontinence questionnaire form. 443Archivio Italiano di Urologia e Andrologia 2021; 93, 4 Pressure-flow study in women with incontinence If we come to underactive detrusor, we see that there are not enough studies and accepted objective criteria in female patients regarding underactive detrusor. The existing nomograms about underactive detrusor have been used to describe male voiding dysfunction (8). We defined that there were 7.9% (n = 80) underactive detrusor our patients. Estimating the prevalence of BOO in women with incon- tinence is problematic in light of the existing literature. A nomogram has been developed to diagnose BOO in women. However, due to the disparities in the patho- physiology of voiding problems compared to men, it has not been widely accepted, especially among urologists interested in this topic. Even so, it is possible to deter- mine female bladder outlet obstruction with the support of pressure-flow studies and clinical symptoms simulta- neously with video-urodynamics (8). It has been seen that even if in women with voiding difficulties and low uri- nary flow symptoms, the correlation between symptoms and urodynamics objective BUO is low, and it is not easy to reach a diagnosis in this way (9, 10). Another clinical entity that should be kept in mind is the possibility of the development of detrusor overactivity secondary to blad- der outlet obstruction (7). As a matter of fact, in our study, the most common storage problem in patients with outflow obstruction was found to be urge type urinary incontinence. In addition, urethral stricture was found in 1.1% of the patients. Although dysfunctional voiding is primarily diagnosed in the pediatric age group, it is one of the most common uri- nary voiding dysfunctions in women with lower urinary tract symptoms. In the literature, dysfunctional voiding was established in women with lower urinary tract symp- toms and urodynamic examination with a rate of 9.6-12% (11, 12). Similarly, we noticed dysfunctional voiding was at a rate of 9.4% in our study. It is a broad-spectrum non-neurogenic disorder involving dysfunction of the lower urinary tract and intestinal tract. Also, it is one of the most common urinary voiding dys- functions in women with lower urinary tract symptoms. We presented treatment options such as behavioral ther- apy (pelvic floor physiotherapy, biofeedback), medical therapy, cognitive therapy and sacral neuromodulation to patients who were diagnosed with this dysfunctional voiding. Urodynamics after evaluation in the outpatient clinic changes the diagnosis by 57% and the choice of the treat- ment plan by 14%, and canalizes the surgical procedure (13-16). The best indicator for this is that 40% of overac- tive bladder patients are diverted for stress urinary sur- gery (8, 17). In another study, it has been indicated that the voiding phase is the most commonly used method to modify the surgical procedure in overactive bladder and intrinsic urinary sphincter deficiency (13). In our study, we found out that the diagnosis changed in 18.4% of patients after PFS. Thus, we think that unnec- essary surgery in 69/684 (10%) patients and inappropri- ate medical treatment in 47/334 (14%) patients with uri- nary incontinence have been prevented. Limitations of our study are being a single-center study with retrospective design, lack of Overactive Bladder Questionnaire (OABQ) and ICIQ scoring in statistical data, no follow-up of the patients after surgery. Another matter of criticism could be that evaluations were not made by a single physician. We also admit that our results do not support a new finding, but we believe that our study with a high number of patients may contribute to clarify the controversial topic of necessity to perform urodynamics before surgery. CONCLUSIONS Urodynamics can provide clinicians with detailed and useful information about lower urinary tract function that may affect medical and surgical decisions. We recom- mend performing pressure-flow studies together with cystometry not to overlook the diagnosis of possible uri- nary voiding dysfunction in female patients with inconti- nence undergoing urodynamic examination. We believe that supporting these data with multi-center and prospec- tive studies will significantly contribute to the literature. REFERENCES 1. Minassian VA, Stewart WF, Wood GC. Urinary incontinence in women: variation in prevalence estimates and risk factors. 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A systematic review of the lit- erature. Neurourol Urodyn. 2011; 30:495-502. Correspondence Kutluhan Erdem, MD kutluhan1988@gmail.com Alper Coşkun, MD dr.alper05@gmail.com Fatih Üstün, MD drfatihustun@gmail.com Fatih Tarhan, MD tarhanf@yahoo.com Department of Urology, University of Health Sciences, Kartal Dr. Lutfi Kırdar City Hospital, Istanbul (Turkey)